Multidisciplinary Integrated Care in Atrial Fibrillation (MICAF): A Systematic Review and Meta-Analysis

Integrated Care in Atrial Fibrillation: A Multidisciplinary Approach to Improve Clinical Outcomes and Quality of Life

Background: Atrial fibrillation (AF) is the most common arrhythmia globally, associated with serious complications such as stroke and heart failure, as well as significant impacts on patients' quality of life. Objectives: This theoretical article explores the role of integrated care in the management of AF, highlighting the need for a multidisciplinary approach that goes beyond rhythm and heart rate control. Methods: Through a review of the literature, this article explores the prevalence of AF, the challenges of diagnosis, the socioeconomic and psychological impact, as well as the benefits of integrating medical, psychological, and social interventions, drawing on insights from studies about integrative care in AF. Results: The findings highlight the challenges of managing AF, including its high prevalence, complex diagnosis, and significant socioeconomic and psychological impacts on patients. Integrated care models, combining medical, psychological, and social interventions, improve treatment adherence, reduce complications like stroke and heart failure, and enhance patient quality of life. Conclusions: Integrated care models hold significant promise in improving outcomes in AF patients through structured, multidisciplinary approaches. Evidence supports reductions in cardiovascular events, hospitalizations, and mortality when adhering to clinical guidelines, emphasizing patient education, and implementing individualized care strategies. Despite challenges, like regional disparities and suboptimal implementation, the integration of multidisciplinary teams and emerging technologies offers a way to enhance care delivery and accessibility. Future efforts should focus on personalizing care, promoting professional collaboration, and taking advantage of technological advances to optimize AF management and promote sustainable health systems.

Mapping provider and consumer voices using the AACTT framework: a focus group study of advance care planning

BACKGROUND

The provision of healthcare is complex. When evidence-practice gaps are identified, interventions to improve practice across multi-level systems are required. These interventions often consist of multiple interacting components and behaviours. To effectively address these complexities, it is crucial to first identify the specific roles and actions required at each stage of the intervention. This approach enables a thorough examination of what is working well and what needs to be optimised. The action, actor, context, target, time (AACTT) framework provides a consistent approach to identifying key elements such as 'who' (actor) does 'what' (action), 'where' (context), 'to or with whom' (target) and 'when' (time). To our knowledge the AACTT has not yet been applied: 1) to specify complex interventions across patient journeys; and 2) to investigate consumer views, despite the importance of patient-centred care.

AIM

Using advance care planning (ACP) as an exemplar complex healthcare process, we describe a method for using the AACTT framework to 1) map a complex model of care across a patient journey 2) capture the consumer perspective; and 3) operationalise these perspectives by comparing across groups and identifying alignments or misalignments.

METHODS

Two groups were recruited (healthcare professionals and consumers). Informed by the AACTT framework, four focus groups discussed the process of ACP across existing care pathways. Maps visually representing the perspectives and preferences of healthcare professionals and consumers were co-created iteratively. Qualitative data was deductively coded to the AACTT framework and inductively coded to identify themes within domains. Maps were circulated for critical feedback and refined.

RESULTS

Healthcare professional (n-13) and consumer perspectives (n = 11) highlighted what is 'currently occurring' in practice, what is 'not occurring', and what 'should be occurring' to align practice with consumer preferences of care. Comparing participant perspectives identified that most misalignment occurred within the actor, context, and time domains. Misalignment was found predominantly in actions 'occurring sometimes', with no converging perspectives reported for the context and time domains.

CONCLUSION

This novel application of the AACTT framework systematically brings in the consumer voice in ways that may influence the delivery of care. This approach to specifying healthcare professional and consumer perspectives across a complex care pathway identifies barriers that are not found with traditional mapping methods or in current applications of the AACTT framework.

Bridging the Gaps in Atrial Fibrillation Management in the Emergency Department

Atrial fibrillation (AF) frequently presents in emergency departments (EDs), contributing significantly to adverse cardiovascular outcomes. Despite established guidelines, ED management of AF often varies, revealing important gaps in care. This review addresses specific challenges in AF management for patients in the ED, including the nuances of rate versus rhythm control, the timing of anticoagulation initiation, and patient disposition. The updated 2024 European Society of Cardiology (ESC) guidelines advocate early rhythm control for select patients while recommending rate control for others; however, uncertainties persist, particularly regarding these strategies' long-term impact on outcomes. Stroke prevention through timely anticoagulation remains crucial, though the ideal timing, especially for new-onset AF, needs further research. Additionally, ED discharge protocols and follow-up care for AF patients are often inconsistent, leaving many without proper long-term management. Integration of emerging therapies, including direct oral anticoagulants and advanced antiarrhythmic drugs, shows potential but remains uneven across EDs. Innovative multidisciplinary models, such as "AF Heart Teams" and observation units, could enhance care but face practical challenges in implementation. This review underscores the need for targeted research to refine AF management, optimize discharge protocols, and incorporate novel therapies effectively. Standardizing ED care for AF could significantly reduce stroke risk, lower readmission rates, and improve overall patient outcomes.

County-Level Integrated Healthcare Practice in China: A Kaiser Permanente-Inspired Approach

Introduction

China's rapidly aging population and rise in chronic diseases put immense strain on the country's healthcare system. To address these challenges, Yuhuan People's Hospital established County-level Integrated Health Organization (CIHO) as part of the Healthy China 2030 initiative.

Description

Based on the Kaiser Permanente (KP) model, the CIHO takes a multi-disciplinary, collaborative approach to deliver integrated care. It brings together various medical specialties, collaborates with community organizations and companies, and implements reforms in information technology and payment models. Through these efforts, the CIHO has significantly improved healthcare delivery in Yuhuan county.

Discussion

Population segmentation relies on data integration and segmentation tools to identify targeted healthcare needs. The allocation and collaboration of health workforce for residents with different health conditions are suggested to be dynamically designed according to both internal and external factors. Corresponding payment mechanism is also an important factor that needs to be taken into consideration.

Conclusion

The CIHO's success has provided a model for integrated, efficient healthcare that could be replicated in other regions of China and offer insights for rural areas in other countries facing similar demographic and epidemiological pressures.

Hospital Utilization and Mortality Post-electrical Cardioversion in Patients With Atrial Fibrillation in a Community Hospital

Background Electrical cardioversion (EC) is a procedure that restores normal sinus rhythm in patients with atrial fibrillation (AF). Data on post-EC outcomes relative to the success of inpatient EC is limited. Methods This is a retrospective study of patients admitted for AF who underwent inpatient EC from January 1, 2017, to January 1, 2021. We collected demographics and clinical, biochemical, and echocardiographic parameters that impact the success of EC. Outcome events were 30-day readmissions and mortality. Results Our study included 54 unique patients who either had EC in the emergency room or as part of their hospital admission course for atrial fibrillation. Most patients were men with an average age of 70 years with traditional risk factors for cardiovascular disease including heart failure, coronary artery disease, and chronic kidney disease. The group who had unsuccessful cardioversion was older than those in the ineffective EC. Mortality at 30 days (p < 0.01), 1 year (p < 0.01), and 30-day readmission rate (p < 0.01) were higher in patients with unsuccessful EC. Conclusion A predictive model for successful EC remains difficult to establish. Patients with unsuccessful in-hospital EC are at high risk for mortality and readmission at 30 days and require a comprehensive pre-discharge multidisciplinary approach and prioritized and individualized post-discharge integrated care.

Does a nurse-led interventional program improve clinical outcomes in patients with atrial fibrillation? A meta-analysis

BACKGROUND

Being the most common type of arrhythmia, atrial fibrillation (AF) is progressively increasing with an annual rate of 5 million new cases. Recent guidelines highlight the importance of using collaborative multidisciplinary teams in order to improve outcomes during management of patients with AF. A nurse-led program including a nurse-directed education, counselling and intervention has shown to improve patients' outcomes in candidates with AF. In this analysis, we aimed to systematically compare the clinical outcomes observed in patients with AF who were assigned to a nurse-led interventional program versus a usual care group.

METHODS

EMBASE, MEDLINE, Http://www.

CLINICALTRIALS

gov , Web of Science; Google Scholar and Cochrane databases were the data sources. The clinical outcomes were considered as the endpoints in this study. This is a meta-analysis, and the statistical analysis was conducted by the RevMan software (version 5.4). Risk ratios (RR) with 95% confidence intervals (CI) were used to represent the data after statistical analysis.

RESULTS

Six studies with a total number 2916 participants were included whereby 1434 participants were assigned to a nurse-led intervention and 1482 participants were assigned to the usual care group. Our results showed that participants with AF who were assigned to the nurse-led interventional group had a significantly lower risk of composite endpoints (RR: 0.82, 95% CI: 0.70-0.96; P = 0.01), heart failure (RR: 0.66, 95% CI: 0.47-0.92; P = 0.02), atrial fibrillation (RR: 0.77, 95% CI: 0.63-0.94; P = 0.01) and re-admission (RR: 0.78, 95% CI: 0.62-0.99; P = 0.04). However, the risks of all-cause mortality (RR: 0.86, 95% CI: 0.68-1.09; P = 0.21), cardiac death (RR: 0.67, 95% CI: 0.33-1.39; P = 0.28), myocardial infarction (RR: 0.70, 95% CI: 0.35-1.42; P = 0.33), stroke (RR: 0.75, 95% CI: 0.44-1.26; P = 0.28), all bleeding events (RR: 1.11, 95% CI: 0.81-1.53; P = 0.51) and major bleeding events (RR: 0.91, 95% CI: 0.56-1.49; P = 0.71) were not significantly different.

CONCLUSIONS

The nurse-led interventional program significantly improved composite endpoints including heart failure and the recurrence of AF, resulting in a significantly lower admission rate compared to the usual care group. However, nurse-led interventional program did not affect mortality, stroke, myocardial infarction and bleeding events. Based on our current results, a nurse-led interventional programs apparently could be beneficial in patients with AF. Future larger trials would be able to confirm this hypothesis.

Systematic Review and Meta-Analysis of Oral Anticoagulant Therapy in Atrial Fibrillation Cancer Patients

(1) Introduction: Cancer and atrial fibrillation (AF) are increasingly coexisting medical challenges. These two conditions share an increased thrombotic and bleeding risk. Although optimal regimens of the most suitable anti-thrombotic therapy are now affirmed in the general population, cancer patients are still particularly understudied on the matter; (2) Aims And Methodology: This metanalysis (11 studies (incl. 266,865 patients)) aims at evaluating the ischemic-hemorrhagic risk profile of oncologic patients with AF treated with oral anticoagulants (vitamin K antagonists vs. direct oral anticoagulants); (3) Results: In the oncological population, DOACs confer a benefit in terms of the reduction in ischemic, hemorrhagic and venous thromboembolic events. However, ischemic prevention has a non-insignificant bleeding risk, lower than Warfarin but significant and higher than the non-oncological patients; (4) Conclusions: Anticoagulation with DOACs provides a higher safety profile with respect to VKAs in terms of stroke reduction and a relative bleeding reduction risk. Further studies are needed to better assess the optimal anticoagulation strategy in cancer patients with AF.